| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
323 |
105 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
109 |
$26K |
| D5110 |
|
12 |
12 |
$10K |
| D0330 |
Panoramic radiographic image |
152 |
152 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
30 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
17 |
$4K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$4K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
87 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$955.32 |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$698.32 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$678.30 |
| D1120 |
Prophylaxis - child |
20 |
20 |
$595.19 |